Telemedicine+Comm Netw+Equipment + Video Conference

8/12/2019 Telemedicine+Comm Netw+Equipment + Video Conference

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Introduction

The purpose of this document is to provide a basic understanding of the essentials of videoconferencing in the health care environment. Its goal is to help readers become familiar withthe following:

History of the video conferencing industry and the advent of telemedicine Key telemedicine program selection and deployment considerations Basic approaches to telemedicine connectivity and management Prominent video conferencing manufacturers and their backgrounds

This document does not specifically recommend any manufacturer. It does not detail the prosand cons of specific products or lines. Capabilities and functionalities offered by eachmanufacturer change at a very rapid pace, and indeed, have changed during the brief time thisdocument was written. Moreover, the best videoconferencing solution differs based on the specific needs of each situation.

The overall goal of this document is to provide readers with the information necessary toevaluate the multiple facets of implementing an organization-specific videoconferencing solutionin this ever-changing environment. In addition, the appendices contain valuable insights fromIndiana health care professionals in their respective organizations telemedicine programs.Finally, to help readers navigate beyond the detail level of this document, a list of questions foruse in vendor interviews and a glossary of telemedicine terms are included.

Video Conferencing OverviewVideo conferencing technology is changing rapidly. Over the past few years, the introduction ofhigh definition video endpoints and integrated room systems has offered such lifelike videoquality that the term telepresence was adopted. However, before considering the moreadvanced systems of today, we will briefly examine where things started and how far wevecome over the years.

HistoryAT&T developed the technology in 1954 and conducted the first video conference at the 1964Worlds Fair held in New York.Although it was a very futuristic concept, it would only take sixshort years until AT&T introduced their first production Picturephone in 1970. Despite manyyears of testing and improvements, the concept was not greeted with much enthusiasm by thepublic and the product ultimately failed. The same fate also met AT&T competitors systems,such as Ericssons early attempt at the video phone.The technology was not forgotten through the late 1970s and found a more receptive audience inthe commercial market in the early 1980s. Although businesses could see a use for thetechnology, it remained extremely expensive. By the mid 1980s, PictureTel (acquired byPolycom in 2001) produced a video conferencing system that cost $80,000 and required datalines that cost roughly $1,000 per hour still far from being practical for most companies toadopt.Through the 1980s and early 1990s, the technology was improved through advancements in datacommunications and video protocols. Some colleges and universities began to use video


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conferencing for classroom sessions and other training opportunities. During this time, the U.S.military also took advantage of the benefits of the technology and was one of the firstcommercial buyers of early systems. In 1991, IBM introduced the first PC-based videoconference. Although it was in black and white, the data line only cost $30 per hour and thesystem cost approximately $20,000. It was a major breakthrough in price and ushered in the

beginning of the desktop video conferencing revolution.

By the mid 1990s, companies like Apple and Microsoft were well on their way to offeringdesktop solutions that offered basic video conferencing capabilities. During this time, manysoftware applications were written for both platforms that enabled users to not only make personto person calls, but also multiparty calls through a reflector serviceor video conference bridge.Also introduced around this time was the capability to view desktop presentations, such asMicrosoft PowerPoint or Excel, as part of the call. Understandably, this application became verypopular within both academia and the military.By 2001, advancements in video, computer, and robotics technology led to the first transatlantictelesurgery, a gall bladder removal, from 4,300 miles away. The surgical procedure was

conducted by a surgeon in New York City on a patient who was located in Strasbourg, France.The surgery was a technological breakthrough in many respects and marked the beginning oftrue clinical capabilities for these types of technologies. Many of the major video conferencemanufacturers were on the path to high definition (HD) video by 2006. Along with theintroduction of HD to set-top video conference units, companies like Cisco Systems, LifeSize,Polycom, and Tandberg were introducing Telepresence suitesspecially outfitted conferencerooms that gave the illusion that remote participants were sitting at the same table. Althoughextremely expensive to own and operate, these highly sophisticated systems were quite popularwithin the corporate arena. Despite the high cost of these systems, companies were able to justifythe expense as a result of increasing travel budgets.The introduction of HD video systems has also had other benefits to the health care field.Specifically, the high resolution cameras are used in clinical applications where viewing injuriesor subtle facial expressions are critical. When combined with other peripheral equipment, such asdigital stethoscopes and other higher-resolution cameras, video conferencing systems havetaken on a new role of importance in providing an avenue of care to hospitals and clinics in bothrural and metropolitan areas.

Market TrendsAs evidenced through its history, video conferencing, like most other technologies, hascontinued to evolve over the years. This evolution has brought the technology into new markets,each with their own special challenges and opportunities. At its core, however, videoconferencing is a communications tool. Regardless of the industry application, videoconferencing enables individuals or groups of people to enhance the communication process.Video conferencing has seen a surge in adoption in todays volatile business environment. Past deployment barriers such as high cost, lack of network bandwidth, and technical expertise havebeen overcome by competition and technical innovation. The driving forces behind the videoconferencing adoption movement include: Reduction in travel costs Time savings Improved communications (ability to see body language,facial expression, etc.)


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Team collaboration Reduction in carbon emissions (green technology)Because the new video systems are able to produce life-like visual images, it is much easier toconduct meetings as if remote participants were physically present. While many of the higherendroom systems offer the benefit of this immersive environment, many of the smaller,personal

video conferencing systems are also beginning to support the telepresence experience. This onlyincreases the likelihood that strong interest in this technology will continue for the foreseeablefuture.

Uses in TelemedicineAs in the corporate environment, the reduced travel costs, time savings, and environmentalbenefits of video conferencing are sought by executives in the medical community. However,video conferencing offers many telemedicine-specific benefits as well. Telemedicine allowshealth care practitioners to offer their services across many different hospitals or clinics withouthaving to travel to each location physically. This increases billing opportunities by allowing theefficiency of being in more places in less time. This can also increase overall job satisfaction and

staff retention.Telemedicine benefits local health care facilities by allowing them to retain patients, as opposedto losing those patients and all associated lab and procedure fees to a larger specialty hospital orclinic. In addition, patient confidence in the rural health facility grows with the number ofservices offered locally. Patient health is enhanced by immediate delivery of certain health careservices. In rural or underserved areas without the specialty practices of larger cities ormetropolitan areas, telemedicine is often the only option for such immediate treatment.Telemedicine also can relieve patients from long travel or stays far away from home. Ill patientsoften benefit

physically and emotionally from staying close to home, especially since the technology allowsfamily to be involved in the virtual care experience. The technology also aids in reducing anyfinancial burden resulting from lost wages or long distance travel. While telemedicine cannotreplace traditional office visits or face-to-face medical examinations, it can provide an excellentmeans of augmenting care when traditional services are not efficient or cost effective (Caputo,2001). Specialty areas have seen expanded use with this technology, including: Cardiology Radiology Dermatology Ophthalmology Pathology Disease State Management HIV/AIDS Mental Health Rehabilitation School-based Services

According to the American Telemedicine Association (ATA), telemedicine encompassesdifferent types of programs and services provided for the patient. Each component involvesdifferent providers and consumers.


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Specialist referral service typically involves a specialist assisting a general practitioner inrendering a diagnosis. This may involve a patient "seeing" a specialist over a live, remote consultor the transmission of diagnostic images and/or video along with patient data to a specialist forviewing later. Recent surveys have shown a rapid increase in the number of specialty and

subspecialty areas that have successfully used telemedicine. Radiology continues to make thegreatest use of telemedicine with thousands of images read by remote providers each year.According to a variety of reports and studies, almost 50 different medical subspecialties havesuccessfully used telemedicine. Patient consultation uses telecommunications to provide medical data, which may includeaudio, still or live images, from a patient to a health professional for use in rendering a diagnosisand treatment plan. This might originate from a remote clinic to a physician's office using adirect transmission link or may involve communicating over the Internet. Remote patient monitoring uses devices to remotely collect and send data to a monitoringstation for interpretation. Such "home telehealth" applications might include a specific vital sign,such as blood glucose or heart ECG, or a variety of indicators for homebound patients. Such

services can be used to supplement the use of visiting nurses. Medical education provides continuing medical education (CME) credits for healthprofessionals and special medical education seminars for targeted groups in remote locations. Consumer medical and health informationincludes the use of the Internet for consumers toobtain specialized health information and on-line discussion groups to provide peer-to-peersupport.

Telemedicine Deployment ConsiderationsPrior to making a decision on the deployment of a telemedicine program, several importantfactors should be considered. Selecting the best video conference system based on evaluation ofkey functionalities is, of course, crucial. Additional areas of focus should include telemedicineperipherals, data networking, room design, and portability.Although the additional areas of focus may seem secondary to the selection of a videoconference system, they each play a significant role in the overall success of a telemedicineprogram. Some telemedicine programs have suffered major setbacks in overall acceptancebecause of incompatibilities between peripheral equipment, poor video or sound quality, and/orthe inability to assess patients due to inadequate exam room configuration. Forethought duringthe developmental stages of the program will ensure a much higher rate of acceptance andsuccess.

Video Conference System Key Functionalities

When video conference systems were first introduced, set standards for audio and videocompression, security, data transmission, etc. did not exist. As a result, manufacturers developedtheir own standards, locking their customers into staying with the same manufacturer if theywanted to add additional locations to their video network.As the industry matured over time, many of the technologies were evaluated and reviewed bystandards organizations, such as the ITU-T (International Telecommunications Union), andadopted as communication standards or protocols. This not only paved the way to uniformity forsystems manufacturers, but also enabled new technology vendors to enter the market quickly byintegrating the common protocols they wished to support. The standards also propelled


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interoperability between various existing manufacturers that desired their systems to work withthe systems of other vendors.When comparing video conference systems to select the best fit for a particular program, thefollowing key functionalities should be considered: High Definition (HD)The visual clarity achieved with HD is far superior to that supported

by standard definition (SD). HD carries nine times the pixel count (or resolution) as compared toSD video conferencing images (Wainhouse Research, 2007). As a result, despite the slightlyhigher price to obtain HD, it is generally recommended for medical applications. Purchasersshould also be aware of industry predictions that SD units (much like analog television sets) willeventually become obsolete and may be removed from the market in the near future. The HDfeature is typically available in 720p/30fps (frames per second), 720p/60fps, or 1080p/30fps.1080p offers a clearer picture (higher resolution) as compared to 720p. In the case of frames persecond (fps), 60 fps offer better motion handling, as compared to 30 fps. Video endpoints willalways scale down and adjust to the system with the least capabilities. Therefore, if endpoint Asupports 1080p/30fps and endpoint B supports 720p/30fps, a video call between the twoendpoints will be conducted at the latter resolution and frame rate. Please note that computer

network bandwidth and performance may be impacted by the introduction of video conferencingequipment within an organization without proper planning. Dual Video(H.239 communications standard)This feature supports two channels of video ina single conference. This allows one video channel to carry a live view of conference participantswhile the other channel shows computer-based meeting content, including slides, spreadsheets,or other presentation material. This dual functionality proves very beneficial in executivebriefings or training and education programs. In health care applications, this feature may berequired to transmit information from telemedicine devices such as stethoscopes or otherdiagnostic systems. Be aware when comparing equipment that some video conferencingequipment manufacturers charge an additional license fee to enable this feature. Dual Monitors This feature supports the ability to connect two video monitors (ortelevisions) to the video conference endpoint. This is particularly helpful if the dual v ideofeature above is utilized. One monitor shows meeting participants, while the other monitordisplays meeting content. However, if a video endpoint does not support dual monitors, it maystill be used in a conference conducted with dual video and will typically create a picture-in-picture (PIP) view of the conference. Peripheral Expansion Ports Video systems utilized in physical health examinationsgenerally require the ability to connect to other peripheral equipment. Peripheral expansion portsenable a health care practitioner to connect examination cameras, stethoscopes, and computers tothe video endpoint equipment. As noted above in the case of digital stethoscopes, the videoendpoint used on the receiving end of the call must also support this type of interaction withperipheral equipment. Be aware that just because a device appears to have the appropriateexpansion port, it may not be functional. Ask vendors specifically about port usability andcompatibility with peripheral devices. Pan-tilt-zoom (PTZ) CameraBesides their obvious functionality, these cameras can beremote controlled by an off-site physician during a video conference. In applications such asmental health, a PTZ camera may help a physician subtly zoom in on facial expressions or betterview body movement that may be missed with the use of a standard fixed-focus or stationarycamera.


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Multipoint Conference Unit(MCU)As noted above, this feature allows a video endpoint toacts as a hub or meeting room for multiple video systems. A built-in MCU typically supportsbetween four and eight total endpoints. Once again, an additional software license may berequired to operate this feature.

BandwidthAll video endpoints come with a maximum bandwidth or throughputsetting. This essentially throttles the performance of the system, impacting overall video qualityand/or the ability to push large amounts of data across the network to the receiving end.Endpoints with higher bandwidth support offer more latitude when dealing with HD videocontent. Video conferencing manufacturers offer varying levels of bandwidth support in theirproduct lines and some charge a license fee to enable higher bandwidth throughput.Security and Encryption(H.235)This encryption standard is not mandated for useacross video conference systems but is recommended for interoperability. Videosystems not supporting this security standard will not be able to participate in securevideo calls with systems utilizing this feature. Firewall Traversal(H.460)This feature enhances a video conference endpoints ability

to transmit data across a network without interception by a network firewall, allowing faster andeasier deployment of the equipment. However, in many cases, modifications will need to bemade to the network switches, routers, and firewalls to fully support video conferencing. [Notethat endpoints offering firewall traversal typically also include network address translation(NAT) support. NAT allows conversion of public internet protocol (IP) addresses to internal IPaddresses, protecting network devices.] Maintenance Contracts and Support AgreementsMost video conferencing manufacturerscharge an annual support fee for each video endpoint or network component being utilized.These fees allow end users to keep video conferencing equipment updated to the most currentversion of system software. While most manufacturers require purchase of a one year supportplan with each new unit, annual renewal is not mandatory. If regularly renewed, recurringmaintenance fees can become substantial in total. It is advisable to inquire about these fees andincorporate them into the operational budget for ongoing sustainability.

Telemedicine Peripherals

Aside from the importance of video conferencing equipment to a telemedicine program, theselection and use of telemedicine peripherals (e.g. special cameras, stethoscopes, etc.) is crucial.Several manufacturers offer telemedicine peripherals, leading to potential problems whenimplementing a telehealth program. Unlike the slightly more mature video conferencingindustry, where manufacturers have been working to adopt set standards to increase systeminteroperability, the telemedicine peripheral market offers no such compatibility. Therefore, it isimportant to make sure all departments involved in the telemedicine program are in agreement asto which manufacturer and model of peripheral will be purchased. Most peripheral devicesrequire either a matching device or a specific software program running on a laptop or PC on thereceiving end. For example, a digital stethoscope from one manufacturer will likely notcommunicate with a digital stethoscope from another manufacturer and two are required forfunctionality. In some cases, such as with an examination camera, no other matching peripheraldevice is required. This type of peripheral device merely transmits the visual image through thevideo conference equipment or stores it on a local computer for later transmission. However, itremains advisable to standardize on one manufacturers product line to help reduce userconfusion and subsequent errors.


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NetworkingWhen the time comes to make a purchase decision on video conferencing equipment, it isadvisable to include someone from the Information Technology department who will beresponsible for administering and/or maintaining the equipment. This is recommendedbecause the video equipment will need to be specifically configured to work on the

organizations data network and, in some cases, communicate with systems outside the localnetworkthus requiring it to get through the equipment that protects the network (firewall).In many cases this requires additional configuration work and takes time to set up properly.In addition to being configured to communicate through the network firewall, the videoconference endpoint will, in some cases, need to be assigned a public IP addressor a specialset of numbers (like a telephone number) that others can dial from their video system. Oncethe address or number is given to clinicians or other personnel, the video endpoint may becalled from another remote system. It is important to note that when connected to anotherclinical office, HIPAA requires that the calls be encrypted for security purposes. This encryption,called AES (advanced encryption standard), is another one of the communication protocols thatare built into most current video conference systems.

Finally, a commonly overlooked aspect of video communications is network capacity orthroughput. Unlike typical computer data that can be broken into bits and pieces and sent overa network in sporadic bursts, voice and video systems require much more bandwidth and canbe severely affected by network congestion or slower speed connections. Therefore, it is veryimportant to plan out how the voice and video traffic will flow across the network, which canbe accomplished by assigning higher priority or quality of service (QoS) to this data throughnetworking hardware. This will increase the effectiveness of the video system deployment aswell as reduce frustration from other users who may potentially experience decreased networkperformance once a video system is introduced.

Room Design

Another important, but easily overlooked element that can affect the performance of equipmentused in a telemedicine program is the concept of room design. Without going into too muchdetail, it is helpful to note that some thought should be given to the furnishings, colors, lighting,and materials that are utilized in rooms that will host patient consultations. The following is acondensed list of things to be aware of when setting up an examination room: Wall Colors Muted pale tones work best; avoid overly bright or very dark colors. Wall Finishes Paint should be flat or semi-flat finish; avoid gloss or enamel finishes andwallpapers that reflect light or contain busy, geometric patterns. Furnishings Decor items, such as mirrors, glass dividers, etc. may reflect light, thus confusingthe camera. These items also may increase sound reverberations in the room, which couldnegatively affect audio transmission. Windows An abundance of sunlight can cast shadows and/or confuse the camera. Blackoutshades or curtains (also colored in pale tones) are helpful in controlling light; interior rooms areideal. Lighting Proper lighting is very important when assessing patient health. Avoid harsh, directlight sources that produce heavy shadows; try to use a combination of diffused fluorescent andincandescent lighting if possible. External light sources such as professional photographic lightfixtures may produce desired results.


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Acoustics Room noise and reverberation can cause echoing and degrade the overall soundquality; the addition of fabric room dividers, draperies, and acoustic wall panels (also colored inpale tones) can greatly enhance the sound quality of a room.

Portability or PermanenceDuring planning, it is necessary to consider program needs for the portability or permanence of

video conferencing equipment. For example, if the equipment will be used in a busy health careenvironment or emergency department with patients in various rooms, it can be helpful tointegrate the equipment with a cart system. For systems that will not require mobility, it ispossible to have the equipment professionally mounted to a wall. Telemedicine carts can usuallysupport easy movement of all necessary video conferencing and peripheral equipment from roomto room. Most carts come configured with the video conferencing equipment, high definitionmonitor, speakers, microphone, and lockable drawer for telemedicine peripheral equipment.Telemedicine cart solutions are typically offered as after-market, purpose-built units bytechnology systems integrators. Some video conference equipment manufacturers also offer cartsolutions as options, however the cart components and style differ from what is available througha custom-built system. Wall-mounted installations generally include mounting the camera and

video conference system (codec) close to the television monitor, using specialized mounts. Thisprovides a professional appearance that is especially beneficial for boardrooms or clinicaloffices. In some cases, wall mounting is also desirable to protect the equipment. In a mentalhealth installation, for example, equipment could be mounted behind a Plexiglas protectivebarrier.

Telemedicine Implementation

There are many scenarios under which video endpoints may be deployed to support atelemedicine program. While it is not possible or practical to detail al document, it is importantto discuss basic connection configurations to provide a general understanding of the variousformats. It is also essential to consider resources necessary for long-term program success.

Single Point-to-Point ConnectionMost video endpoints will likely be used for clinical applications where a system will be locatedin the emergency department, an examination room, or a clinical office. On the other end,typically at the point where the specialist reside simple scenario, if endpoint A calls endpoint B,that would be referred to as a point. Although this call can traverse private communications linesbetween the two endpoints, it is also possible that one of the endpoints will be connected to theInternet (not a private data circuit). In either case, special network configuration will need to beorder to assure that calls can connect in the intended fashion.

Multi-Point Connection with Internal MCU (Bridge)

Much like some voice telephone calls, it sometimes becomes necessary to add another party tothe call to obtain additional insight, etc. one of the call participants must perform the necessarysteps to bring in an additional caller.Most business telephone systems support this conferencing feature, as do most cellulartelephones. In the case of a phone call, the telephone system contains the necessaryintelligence to perform this task.However, in the example above of our simple point to point call, there is no underlying networkthat possesses the necessary ability to bring in an conferencing endpoints are sold with builtbridges perform the necessary call processing that enables the ability to add other video


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all such scenarios in this resides, will be another video endpoints to the call. Depending on themake and model of the endpoint, some of the in MCUs can support 4 8 total sites on any givencall.Although purchasing an endpoint with an internal MCU does cost more than a standard unit,it might be worth the extra money important to note that the endpoint that hosts the call or

brings in the additional endpoint is acting as a hub for the call and therefore will requireadditional network bandwidth to support the added endpoints.In this example, endpoint A is able to conference in both endpoint B and C together on the call.All participants are able to see one another at the same time in what is called continuouspresence. This means the video into a split screen layout which is presented to all participants.

Multi-Point Connection with External MCU

In some cases it is necessary to add many participants to a call be supported with a built-inMCU. If that situation were to arise, it would become necessary to leverage a larger, externalMCU that is specifically designed MCUs are designed to support various numbers ofconnections (or ports).

The higher number of ports an MCU can support, the higher its relative cost. For manyorganizations, however, large video bridges are a necessity a meetings at a much lower cost thanhaving people physically attend them in person. In addition, it is also possible to daisy chainmultiple MCUs together to create an even larger pool of endpoints if needed. to have thiscapability in case the need arises. It is also that endpoint A is able to combine all three endpoints

These more complex systems might not see much use in a clinical environment. However, theymay have practical application for administrative meetings or group training purposes, allowingmany people to attend from various locations. In the illustration below, the MCU is configured tocreate a virtual conference room where many participants are able to join or exit the meeting asdesired. Most MCUs have the ability to be integrated into the organizations electroniccalendaring system (for example, Microsoft Exchange) where meetings may be established at settimes. In this situation, the MCU can be set to automatically call the required endpoints at thestart of the meeting, therefore making the conference process completely automated.

Similar to recent video conferencing units, most current MCUs will operate with video endpointsfrom various manufacturers. This wasnt always the case, which obviously caused problemswhen participants who used video endpoints from differing manufacturers werent able toconnect through the MCU. However, much like the evolution of video endpoints towardstandards-based communications, most MCUs are also now designed to embrace the sameprotocols, thus making them much more versatile and cost effective.Another important feature of some MCUs is the ability to add recording and streamingcapabilities to the system. These options, typically in the form of a software feature that can beenabled with a license or through the addition of an external piece of hardware, can greatlyenhance the usefulness of the equipment. For example, if some staff members were not able toattend an important video conference, they would have the ability to rep call at a time that isconvenient for them. In addition, if a message needed to be delivered to the entire organization,the video streaming (network broadcasting) option would be one way to achieve that goal.

Endpoint Management Solutions


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Much like managing other computer or information technology assets, video conferencingequipment requires occasional maintenance. This may include software updates, configurationchanges, or administration assistance before or during a call. In these situations, a speciallytrained administrator will need to perform the desired work.In larger organizations, there may be one or two video system administrators that are designated

to only work on the video system infrastructure. However, in smaller organizations where ITstaff may be limited or non-existent, an outsourced entity may be required. In either case, it isimportant to know that the video endpoints can be maintained remotely whileconnected to the organizations local area network (LAN).In smaller deployments, the video endpoints may be managed individually via a managementconsole that resides on each unit. This password protected interface will allow a technician toadminister the system and perform the work necessary. The administrator may also perform thiswork from a remote location if the data network is configured to allow access to the videoequipment.Going one step further, for larger deployments where multiple video units have been installed,each of the video conferencing manufacturers have developed special software management

platforms that can assist the video administrator in maintaining the equipment. This software,which is sold separately and resides on dedicated computer hardware, is configured tocommunicate with each video endpoint. This, in turn, allows the administrator to troubleshoot orupdate multiple video endpoints at once, therefore saving a significant amount of time sometimes critically important in a clinical setting. Each of the manufacturers discussed offerstheir own proprietary endpoint management software, as follows: LifeSize Control Polycom Converged Management Application (CMA) and CMA Desktop Tandberg Management Suite (TMS)Regardless of deployment size, it is vitally important to allocate resources for systemmaintenance during planning of a telemedicine program. Staffing (or budget for externalassistance) must be allocated for a successful long-term telemedicine outcome.

Video Conferencing Manufacturers

As with most other businesses, the landscape of video conferencing manufacturers has changedover time through business acquisitions, mergers, and failures. This has left us where we are attodaywith a handful of manufacturers that we will focus on for the purpose of this document.As you can see below, the top three manufacturers comprise 83% of the United States marketshare. Anecdotal evidence indicates that a similar breakdown exists within the health care space.

Polycom

Polycom is one of the industrys most entrenched players. Founded in 1990 and based inPleasanton, California, Polycom has a long heritage in voice communications. Polycom holdsvarious audio technology patents many of which are used across their extensive line oftelephones, speakerphones, and HD video systems. Some of Polycoms technical advancementshave also been integrated into systems offered by other manufacturers. According to companyreports, global revenue for fiscal 2008 topped $1.1 billion for all product lines (Ben Worthen,2009). Polycom sold approximately 44.4% of all video conferencing endpoints in the secondquarter of 2009 (Ben Worthen, Justin Scheck, 2009). Along with a strong video endpoint


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business, Polycom also maintains approximately 25% of the video network infrastructure market(Frost and Sullivan, 2008).Polycom offers an extensive line of voice, video conferencing, and network infrastructuresystems. Their popular HDX line fits well within the operational requirements for telemedicineuse. The HDX offering ranges from the HDX 4000 all-in-one system capable of 720p resolution

(list price $7,999) up to the component style (separate video codec and camera) HDX 8006system supporting 1080p video resolution (list price $17,499).

Tandberg

The oldest in the market, Tandberg was established in 1989 and has grown into one of theindustrys most notable video conference equipment providers in endpoints and infrastructuresystems. Headquartered in Norway and New York, Tandberg has developed an extensive HDvideo product lineup that spans from the computer desktop to fully integrated systems in theboardroom. As an early market presence, Tandberg has become a fixture in corporations thatembraced the technology early on.Tandberg reported revenue for fiscal 2008 of $809 million (Ben Worthen, 2009) and sold

roughly 33.3% of all video conferencing endpoints in the second quarter of 2009 (Ben Worthen,Justin Scheck, 2009). Tandberg also made a strong play for the video infrastructure market withthe purchase of equipment manufacturer, Codian, in 2007. With that purchase, Tandbergessentially leveled the playing field with Polycom by offering end-to-end video communicationssystems.The Tandberg product line features a wide variety of video endpoint systems and infrastructuresolutions (Codian) that work well for telemedicine applications. Standard Tandberg choicesinclude the all-in-one 1700 MXP (list price $7,990) and the component style Edge series(starting list price $8,400), both capable of 720p resolution. The newer Quick Set C20component, supporting 1080p video resolution (list price $7,900), has also become a popularchoice for health care programs.

LifeSizeLifeSize is relatively new to the video conferencing market, yet has a respectable market sharefor its short existence. Founded in 2003 and based in Austin, Texas, LifeSize has quickly gainedattention as a technology innovator. Noted as being the first company to introduce commerciallyavailable HD video conferencing endpoints in 2005, LifeSize essentially pushed the industry intothe next phase of maturity with HD systems. Since LifeSize is a private company, actual salesnumbers are hard to determine, however it is estimated that LifeSize holds approximately 6% ofthe U.S. video conferencing market (Ben Worthen, Justin Scheck, 2009). LifeSize maintains thatsales have grown by over 140% from October 2008 through October 2009 and include 800 newcorporate customers every quarter. Although the LifeSize product lineup includes a more limitedvariety of video endpoints compared to the other manufacturers, both their endpoint systems andinfrastructure equipment (through Radvision) are gaining increasing notoriety within the healthcare market.From the recently released component style Passport offering 720p video resolution (list price$2,499) to the Express 220 system supporting 1080p resolution (list price $6,999), LifeSize hasgarnered attention for their price/performance value.

Other Video Endpoint Manufacturers


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Although less prominent in terms of market share, other video endpoint vendors are present inthe marketplace.Most notably, that list includes: Aethra Italian manufacturer offers a full lineup of video systems Cisco Systems Offers network-focused, telehealth and telepresence room systems

HP Focused on larger, more expensive telepresence systems Radvision Offers few endpoints; focused mainly on infrastructure solutions Sony Offers a range of video cameras and endpoints from desktop to larger HD systemsEach of the companies above occupies sizable portions of the remaining video endpoint market.In terms of broad deployment in the health care market, however, these systems have either metlimited acceptance or their systems are not well matched for the application (i.e. larger,integrated boardroom installations). Regardless, it must be noted that if an organization were todeploy video endpoints in their hospital or clinic from one of these vendors (i.e. Aethra or Sony),they would likely communicate adequately with systems from Polycom, Tandberg, or LifeSize.

Manufacturer ChangesCisco Systems, a communications industry powerhouse, has very recently acquired Tandberg for

$3.4 billion. Only time will tell how the combined companies manage their product lineup andchart the course for the future of their video communications business. In addition, LifeSize wasvery recently acquired by Logitech. It is not yet known if this new financial backing will allowLifeSize to expand upon their innovative focus to become an even more formidable competitorin the enterprise environment, or if Logitech will encourage LifeSize to grow the endpointbusiness in a more mainstream, consumer-grade manner. Meanwhile, rumors continue to fly thatPolycom is a potential acquisition target of either Hewlett Packard or Avaya, indicating thatmore industry changes could be on the horizon. Regardless, all of the recent activity showsconfidence in the belief that visual communications will see a much stronger surge of growth inthe future as more organizations move to incorporate the technology.

Alternative Video Conferencing SolutionsThere are, of course, many approaches to video conferencing other than those presented thus far.For example, dozens of companies offer software only, web-centered video conferencingsolutions. Solutions popular with small businesses and individuals seeking free or low-cost face-to-face communication include: Skype ooVoo SightSpeed Microsoft (LiveMeeting) MegaMeeting NefsisWhile many of these systems do a fine job delivering essential video communications (some alsooffer meeting content or computer desktop sharing), most are not standards-based. Thisessentially means that these systems will only work within their own communicationsenvironment and will not communicate with other video systems. This can be especiallyproblematic if it becomes necessary to communicate with standards-based video endpoints or theweb-based systems of another provider. For example, Skype users cannot communicate withSightSpeed users, and vice versa.


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These systems also may not guarantee the level of security desired for transmission of patientdata. It is important to be aware of legal and regulatory requirements before making a decision.See Appendix A (pages 28- 29) for further information regarding HIPAA and other complianceissues.In addition to web-based solutions, the major video conferencing manufacturers (along with a

few others) have begun offering their own versions of PC-based soft client video conferencingsystems. While the premise is similar to that of web-based offerings, these solutions are insteadbased upon dedicated network hardware systems deployed within an organization. Below is a listof notable companies offering these solutions: Cisco (Cisco Unified Videoconferencing) LifeSize (LifeSize Desktop) Polycom (CMA Desktop) Radvision (Scopia Desktop) Tandberg (Movi) Vidyo (VidyoDesktop)These options typically resolve the issue of communicating with standards-based video

endpoints. However, they each present their own distinct set of deployment considerations. Asthese systems usually require comparatively significant up-front costs, they tend to be lessattractive for new programs than video endpoints. They are also susceptible to viruses and otherPC-related issues.One other unique video conference system specific to telemedicine is provided through InTouchHealth. This PC based, video-centric system is part of a robotic cart platform that can beremotely driven and operated by an off-site physician. While technically very similar to a videoconference system mounted to a non-robotic cart, the InTouch unit is completely wireless andoperates without manual assistance from hospital staff. While offering the freedom to workindependently, just as if the physician were making rounds in person, the technology requires aunique infrastructure of wireless network equipment as well as robotic controls on the physicianside. This proprietary environment mandates a significant investment in hardware and servicesand should be considered only if long-term financial resources are able to sustain the system.

Conclusion

The field of telemedicine is projected to be an increasingly prominent component of the healthcare delivery system, especially as the American geriatric population continues to increase. Thetechnology trends currently present in the healthcare market will likely mature into the standardof care for delivering services to populations facing unique barriers to access. It is essential thatforward-thinking health care leaders understand the road we have taken to reach this point anduse all available information to evaluate opportunities for their patients and organizations in thefuture.

Documents

Telemedicine+Comm Netw+Equipment + Video Conference